Personality Disorders

by Rethink

Introduction

Each of us has a personality or group of characteristics (called traits) which influence the way we think, feel & behave and makes us a unique individual. Someone may be described as having a 'personality disorder' if their personal characteristics cause regular and long term problems in the way they cope with life and interact with other people. It's possible that some people with these disorders never come into contact with the mental health services. Those who are given a diagnosis of personality disorder may feel, perhaps understandably, that they are being blamed or criticized or that they are somehow responsible for their problems. There are a number of types of personality disorder. They are generally present from a fairly early age.

how common are personality disorders?

Approximately 10-13% of the population have a personality disorder. Personality disorders are more common in younger age groups (25-44 year age group) and are equally distributed between males and females. Personality disorders are most abundant in the prison population with 78% of male prisoners on remand, 64% of male sentenced prisoners and 50% of female prisoners found to be suffering from a personality disorder.

how is personality disorder diagnosed?

As with mental illness, there are no tests (like analyzing a blood sample) to check whether personality disorder is present. Psychiatrists have to look for signs and characteristics and may use classification systems (like ICD10 and DSM IV) to help them identify groups of traits as particular disorders. In making a diagnosis, doctors need to find out a great deal about the person concerned by talking to them, their family and perhaps others who know them. But reaching the correct diagnosis can be difficult because:

• people being assessed by a psychiatrist may conceal information about themselves (which is why it is important for doctors to talk to others close to the person
• symptoms like anxiety or paranoia might indicate a personality disorder or be associated with mental illness
• symptoms of personality disorder may be masked by the use of street drugs or alcohol
• it is possible for someone to have both a mental illness and personality disorder
• people with personality disorders may also have other conditions, like depression.

In practice, it is very important that doctors recognize any symptoms present which will respond to treatment, especially because personality disorders carry an increased risk of self-harm and suicide.

If someone has functioned well during childhood and adolescence, it is unlikely that a diagnosis of personality disorder would be appropriate. It is also important that any psychosis present should be treated appropriately before a diagnosis of personality disorder is considered.

In Rethink's experience, a diagnosis of personality disorder is sometimes given inappropriately to people who:

• are 'non-compliant' or difficult to engage in treatment;
• do not respond to most treatments;
• are difficult to 'manage' in settings like a hospital ward;
• are difficult to diagnose.

What Are the Symptoms of a Personality Disorder?

The diagnosis of personality disorder includes a number of conditions with different symptoms. However the symptoms of all personality disorders are enduring and play a major role in most, if not all, aspects of the person's life. In many many disorders the symptoms vary in presence and intensity, in personality disorders the symptoms typically remain relatively constant.

To be diagnosed with a personality disorder in this category a psychiatrist will look for the following criteria:

1. Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder. The history of symptoms can be traced back to adolescence or at least early adulthood.
2. The symptoms have cause and continue to cause significant distress or negative consequences in different aspects of the person's life.
3. Symptoms are seen in at least two of the following areas:

• Thoughts (ways of looking at the world thinking about self or others, and interacting)
• Emotions (appropriateness, intensity, and range of emotional functioning)
• Interpersonal Functioning (relationships and interpersonal skills)
• Impulse Control

What Are The Different Types Of Personality Disorder?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a guide to diagnosis, divides personality disorders into three clusters:

• A) odd/eccentric
  • paranoid
  • schizoid
  • schizotypal


• B) dramatic/erratic
  • antisocial
  • borderline
  • histrionic
  • narcissistic
• C) anxious/inhibited
  • dependent
  • avoidant
  • obsessive-compulsive

In addition there is the controversial label of dangerous and severe personality disorder. This will be discussed at the end of this page.

Cluster A

paranoid personality disorder

The person with a paranoid personality disorder essentially has an ongoing, unbased suspiciousness and distrust of people. Along with this they are emotionally detached. In order to have this diagnosis, the person would have to have seen others as malicious intentions, by early adulthood in different situations, as indicated by a number of different factors. These factors include:

• suspicion that others are exploiting or deceiving them
• belief that others may not be loyal or trustworthy
• beliefs that there are threats or attacks on their character in innocent statements that others do not see
• bears persistent grudges.

As a rule, those with paranoid personality disorders can be very draining to be around, as their constant habit of blame and suspicion makes you feel the need to reassure them on an ongoing basis. Unfortunately when reassurances are made, those with this disorder hear contradictory evidence. They view it as more evidence that harm will be done to them.

They tend to think in hierarchy: who controls the power. They want to know who has the power in any given situation. they tend to drive people away from them, and thus have few friends, proving to themselves even more that there is a conspiracy afoot against them. This leads them to have a very lonely life.

When diagnosing this condition, schizophrenia and psychotic features of mood disorders must be ruled out as well as being the result of a psychological event or a general medical condition.

schizoid personality disorder

A person with schizoid personality disorder has minimal social relationships, expresses few emotions (especially those of warmth and tenderness), and appears to not care about the praise of criticism of others. They appear absentminded and aloof, but are actually very shy. While they do not do well in contact in groups, they may excel when placed in positions where they have minimal contact with others.

schizotypal personality disorder

Schizotypal personality disorder is marked by a lack of, and reduced capacity for, social and interpersonal relationships. The person with this disorder also has cognitive distortions and eccentricities of beaviour. They often have magical thinking (if I think this, I can make that happen), paranoia, and other seemingly strange thoughts. They may talk to themselves, dress inappropriately, and are very sensitive to criticism.

When diagnosing schizotypal personality disorder, diagnoses of schizophrenia, mood disorder with psychosis, another psychotic disorder or a persistent developmental disorder are ruled out.

Cluster B

antisocial personality disorder

Antisocial personality disorder has a prevalence of 2-3% in the population. It is more common among men than women, in younger people, those of low socio-economic status, single individuals, the poorly educated and those living in urban areas. It is the most common type of personality disorder found in the prison system with 63% of male remand prisoners, 49% of sentenced prisoners and 31% of female prisoners suffering from this illness. Antisocial personality disorder results in what is commonly known as a sociopath. This disorder is defined by an ongoing disregard for the rights of others, since the age of 15 years. Some examples of this regard are:

• reckless disregard for the safety of themselves or others,
• failure to conform to social norms with respect to lawful behaviours,
• deceitfulness such as repeated lying or deceit for personal profit or pleasure
• lack of remorse for actions taht hurt other people in any way.

Additionally, they must have evidenced a conduct disorder before the age of 15 years, and must be at least 18 years old to receive this diagnosis.

When diagnosing antisocial personality disorder schizophrenia or a manic episode must be ruled out.

borderline personality disorder

Borderline personality disorder refers to the symptoms being on the borderline between psychosis and neurosis. Borderline personality disorder (BPD) occurs in approximately 2% of the population. It accounts for 10% of all mental health outpatients and 20% of psychiatric inpatients. 75% of those diagnosed are women. It is a disorder in which a person has a pattern of unstable personal relationships, a self-image that is not well formed, and poor impulse control in areas such as spending, sexual conduct, driving, eating, and substance abuse. Additionally, the person suffering from BPD fears abandonment and will go to any length to prevent this. they feel chronic emptiness.

One of the hallmarks of BPD is known as "splitting". This is where the person with BPD will swing between idealizing and devaluing people in relationships. They will pit people against one another, making one group the "white hats" and the other the "black hats". A person is either good or bad, the person with BPD being unable to reconcile that there is both good and bad within a person. This categorization of a person may shift from day to day, the person being good one day and bad the next.

There may be suicidal threats, gestures or attempts made by the person with BPD. There may also be self-harm that occurs. Their mood may be prone to outside stress with feelings of depression and anger readily provoked, with anxiety also a common occurrence. With extreme stress, the person with BPD may experience paranoid ideation, or may have dissociative symptoms such as "running on automatic" and disconnecting from reality.

histrionic personality disorder

Histrionic personality disorder is characterized by a person who is always calling attention o themselves, who are lively, and overly dramatic. They are overly dramatic, and minor situations can cause wild swings in emotions. They easily become bored with normal routines, and crave new, novel situations and excitement. In relationships, they form bonds quickly, but the relationships are often shallow, with the person demanding increasing amounts of attention.

narcissistic personality disorder

Narcissistic personality disorder is a disorder in which a person has a grandiose self-importance, preoccupation with fantasies or unlimited success, a driven desire for attention and admiration, an intolerance of criticism, and disturbed self-centered interpersonal relations. they are often referred to as being conceited. They generally have a low self-esteem as well. They act selfish interpersonally, with a sense of entitlement.

Cluster C

dependent personality

Dependent personality is manifested via passively allowing others to assume responsibility for major areas of ones life due to lack of self-confidence or lack of ability to function independently. This leads to the person making their own needs secondary to the needs of others, and then becoming dependent on them. While everyone is dependent on others of some parts of their lives, those with dependent personality disorder are dependent on almost all major areas of their lives, and view themselves poorly, and good only as expensions of others.

avoidant personality disorder

Avoidant personality disorder is where a person has an extreme fear of being judged negatively by other people, and suffers from a high level of social discomfort as a result. They tend to only enter into relationships where uncritical acceptance is almost guaranteed, undergo social withdrawal, suffer low self-esteem, but have a great desire for affection and acceptance. However, they do not want the affection as much as they fear the rejection.

obsessive-compulsive personality disorder

Obsessive-compulsive personality disorder is characterized by a person who has a decreased ability to show warm and tender emotions, a perfectionism that decreases with the ability to see the larger picture, difficulty in doing things any way but thier own, and an excessive devotion to work, as well as indecisiveness. Essentially, everything must be just right, and nothing can be left to chance. Obsesive-compulsive personality disorder is different from obsessive-compulsive disorder and the latter must be ruled out.

dangerous and severe personality disorder

The government first introduced the term dangerous and severe personality disorder in a consultation paper 'Managing Dangerous People with Severe Personality Disorder' in 1999, which proposed how to detain and treat a small minority of mentally disordered offenders who pose a significant risk of harm to others and themselves. Specialist services to deal with these people, most of whom are thought to be serious violent and sex offenders, were proposed in the white paper 'Reforming the Mental Health Act ' in December 2000.

The term DSPD has no legal or medical basis and many doctors regard it as a political intervention. DSPD is thought to be an extreme form of antisocial personality disorder - the diagnosis most commonly associated with psychopathy. Head of Whitemoor DSPD unit said that people would need a long history of sex or violent offenses to meet the criteria of DSPD.

It is thought that there are 200-2,400 people in England and Wales that are thought to have DSPD. The home office estimate that, 1,400 are already in prison, a further 400 are patients in high security psychiatric hospitals, with between 300 and 600 in the community. about 98% of those with DSPD are believed to be men. Since the new disorder's definition in unclear, these figures may be speculation.

Currently people in DSPD units receive a psychological therapy called dialectical behavioral therapy (DBT), rehabilitation programs and reoffending reduction courses. The effectiveness of these is not yet proven.

What Causes Personality Disorders? Mortality Rates

Like other psychiatric illnesses, it is thought that personality disorders are caused by a number of factors. These include parental upbringing, one's personality and social development as well as genetic and biological factors.

genetic causes

A large amount of research indicates that personality disorders are inherited to a significant degree. The most dramatic research in this area are the studies of identical twins who were adopted separately at birth, raised in different households and then found to have similar personality traits when studied as adults.

psychological causes

A separate body of research shows that the vast majority of patients with personality disorders were abused as children. 75% of people diagnosed with borderline personality disorder have experienced physical or sexual abuse. Abuse can come in the form of physical, sexual or just not being parented properly. Childhood is the time to learn to cope and manage intense emotional changes and this is one of the most important goals of parenthood. Children who are abused often do not learn these lessons, thus they are more likely to have difficulty regulating their emotions as adults.

Mortality rates

Personality disorders are associated with suicidal behaviour although this varies considerably between the diagnoses. People with borderline and antisocial personality disorders are at greatest risk of suicidal behaviors. Because some personality-disordered people engage in impulsive and dangerous behaviour they have an increased mortality rate. Antisocial personality disorder is associated with a significant excess of unnatural causes of death (largely suicide, accidents and homicides). Antisocial personality disorder is also a risk factor for both sudden violent death and accidental injury. It has also been found to be associated with HIV risk-taking behaviour.

There is also a strong association between personality disorders and substance misuse. It is estimated that 34-100% of people with substance misuse problems also have symptoms of a personality disorder with the most prevalent being antisocial personality disorder.

How Is Personality Disorder Treated?

In the past personality disorders were considered to be largely untreatable. This has recently been challenged and in 2003 the National Institute for mental health in England published a report 'Personality Disorder, no longer a diagnosis of exclusion' which laid out effective ways in which people with personality disorders can be treated. These include psychological and drug therapies. In order to decide which treatment will be suitable for you you should ask your GP or psychiatrist for an assessment.

Psychological Treatments

Dynamic psychotherapy (also known as psychoanalytic psychotherapy)

• Dynamic psychotherapy recognises that problems in the present may have thier roots in past experience and that current behaviour may be motivated by feelings derived from that experience. Dynamic therapists assume that such problems will come out in the relationship with the therapist as well as in other relationships and that the therapeutic relationship ios the central focus of therapy.
• Treatment is generally long term (up to 2 years)
• The treatment focuses on the therapeutic relationship betwen patient and therapist, the individual's emotional life and defences.
• The therapy uses the relationship between patient and therapist as a way to understand how the internal world of the individual affects relationships.

Cognitive Analytical Therapy (CAT)

• CAT involves a therapist and a client working together by looking at what has hindered changes in the past in order to understand better how to move forward in the present. Questions like 'why do I always end up lile this?' become more answerable.
• CAT focuses its attention on discovering how problems have evolved and how the procedures devised to cope with them may be ineffective. It is designed to allow clients to gain an understanding of how the difficulties they experience may be made worse by their habitual coping mechanisms. Problems are understood in the light of clients personal histories and life experiences. The focus is on recognizing how coping strategies started and how they can be adapted and improved, then activating the clients own strengths and resources, plans are developed to bring about change. In this way clients gain skills to help them manage their lives more successfully and to continue.
• The work is active and shared between the client and the therapist.

Cognitive Behavioral Therapy (CBT)

• CBT combines two very effective kinds of psychotherapy - cognitive therapy and behaviour therapy. Behavior therapy helps you to weaken the connections between troublesome situations and your habitual reactions to them, reactions such as fear, depression or rage and self-defeating or self-damaging behaviour. It also teaches you how to calm your mind and body so you feel better, think more clearly and make better decisions. Cognitive therapy teaches you how certain thinking patterns are causing your symptoms - by giving you a distorted picture of what's going on in your life and making you feel anxious, depressed or angry for no good reason or provoking you into ill chosen actions.
• It is likely to take up to 30 sessions of treatment, of which the initial ones help to define the areas that need working on by looking at pas, present and future experiences.
• The therapist takes on an active role in solving your problems. The program includes homework and involves testing core beliefs and structures.

Dialectic Behavioral Therapy (DBT)

• This is a special adaptation of CBT designed specifically for people with borderline personality disorder.
• DBT maintains that some people, due to invalidating environments during upbringing and due to biological factors as yet unknown, react abnormally to emotional stimulation. Their level of arousal goes up much more quickly, peaks at a higher level, and takes more time to return to baseline. This explains why 'borderlines' are known for crisis-strewn lives and emotions that shift rapidly. Because of their past invalidation, they don't have methods of coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task.
• DBT consist of two parts, once weekly psychotherapy sessions exploring a particular problematic behaviour and weekly group therapy sessions in which relating and communicating with people, distress tolerance/reality acceptance skills, emotion control and mindfulness are tough. In crisis, individual therapists are available over the phone.
• DBT is directed at reducing harm.

Therapeutic community treatments)

• Therapeutic communities provide intensive psychosocial treatment which may include a variety of therapies but where the therapeutic environment itself is seen as the main agent of change
• They include democratic and concept types, the former including members of the community as decision makers.
• External control is kept to a minimum; members of the community take a significant role in decision making and the everyday running of the unit.

Drug Therapies

Anti psychotic drugs

• Have been shown to have variable results in controlled trials
• Claimed they may cause a reduction in hostility and impulsivity
• 'Schizotypal features are helped the most
• Atypical narcoleptic may offer advantages

Antidepressant drugs

• Both tricyclic and SSRIs have been recommended in the treatment of borderline personality disorders
• Improvement in borderline patients may be linked to depressive symptoms rather than personality pathology.
• Impulsiveness is particularly improved and SSRIs may offer advantages in this respect.

Mood stabilizers

• Lithium, carbamazepine and sodium valproate have all been used to treat symptoms of mood disorder in those with personality disorder.
• There is weak support for the notion that cluster B (antisocial, borderline, histrionic, and impulsive) personality disorders may be helped by mood stabilizers.

About the Author

www.rethink.org
Rethink is the largest severe mental illness charity in the UK. We are dedicated to improving the lives of everyone affected by severe mental illness, whether they have a condition themselves, care for others who do, or are professionals or volunteers working in the mental health field.